Clark, Warren C fraktiN OF Q [ 3Q1YJ
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director I 1 r ' V DiN L\
Name OL. VC V` 9-'0 e-d. Mk.Case # 3 1
Date of Cremation % - 2- 4
(12
Time Cremation Started -3 0 ./.1/1 _
Time Cremation Completed . 3 fj f //
Type of Container 4 d �� (%C1 t - f�Jf GtRS� GF13A4(
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Remarks:
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08I1E/1596 13:59 516-792-1267 REGANRDEt+IY *i345 PAGE 02/02
5) r
TOWN OF DUEENSOURY
. PINE VIEW CEMETERY
ab
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
•
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium. in
accordance with and subject to its Rules and Regulations to
cremate the remains of:
Warren Clark male
(Name) _ iBesK)
22 Pro'spect Drive Queensbury New York 12804
(Street) (City) T (State) (Zip Code)
who died an 15th day of August 19 96
at_ Glens' Falls Hospital Glens Falls, New York
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Linda Paquin RR 158, Wallingford, VT. 05773
(Name) (Address)
Relationship to the deceased niece
Name of Funeral Home Regan and Denny
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to direct the disposition of
the cremated remains, that any personal possessions have either
born removed or may be destroyed, and agree to protect, defend
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them by
reason of or connected with the cremation of *aid remains as
directed, whether such Claims or demands arl 'Dr are not wholly
groundless, false or fraudulent.
(Witness> (Address)
iynature of R ative or Legal Rep. and Address)
•
Signed on this date: August 15, 1996